Roteiro de Entrevista para Avaliação Psicológica

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ANAMNESE R O T E I R O D E E N T R E V I S T A P A R A A V A L I A Ç Ã O
P S I C O LÓ G I C A
DADOS DE IDENTIFICAÇÃO:
 Nome: Data de Nascimento: Idade: 
 Religião: Curso: Centro: Período: Matrícula: 
Protocolo:
Contato: Encaminhado por:
 ENCAMINHAMENTO: 
PROFISSIONAL RESPONSÁVEL:
DADOS DE INDENTIFICAÇÃO DOS PAIS:
 Nome Pai: Idade: Profissão: Empresa: 
Grau de instrução:
 Nome Mãe: Idade: Profissão: Empresa: 
Grau de instrução: 
Endereço: 
Telefone: E-mail
Estado civil:
 03- QUEIXA PRINCIPAL:
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 04- EVOLUÇÃO DA QUEIXA: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
-Início da queixa:
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 - Súbita ou progressiva:
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 - Quais as mudanças que ocorreram/ o que afetou:
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Sintomas:
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 05-QUEIXAS SECUNDÁRIAS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
06- HISTÓRIA CLÍNICA:
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 -Doença crônica
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 -Uso de medicamentos. Quais: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
-Casos de internação: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 -Enfrentamento: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 -Sintomas físicos e/ou psicológicos:
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- Psicoterapia/fono/fisio/neuro/psiquiatria: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Hábitos Alimentares: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Para crianças ou adolescentes:
- Condições de Nascimento:
 - Desenvolvimento Neuropsicomotor: 
- Doenças infantis: 
- Casos de convulsões,epilepsia,desmaios etc:
 - 07- HISTÓRIA FAMILIAR: 
Composição Familiar: 
(genotograma) 
-Dinâmica Familiar:
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 - Eventos Significativos 
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-Rede de Apoio: _____________________________________________________________________________________________________________________________________________________________________________________________________________________
08- HISTÓRIA SOCIAL:
 - Vida Social:
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 - Hábitos de lazer:
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 - Inserção em Grupos:
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 - Rede de Apoio: 
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09- DADOS ESCOLARES:
 - Casos de reprovação: 
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- Áreas de dificuldade: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Hábitos de Estudo:
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 10- CONSIDERAÇÕES FINAIS:: 
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 11- SUGESTÃO DE ENCAMINHAMENTO: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Assinatura do profissional:____________________________________________